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San Joaquin County Environmental Health Department <br /> DATE 1 3 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION 9 LOP <br /> sS.tk 7.Ctlt1;M14lSElfQ_Il OMIY <br /> OWNER 104 - CAM 9 iI UNIT IV <br /> OWNER FILE:COMPLETETHEFoLLowAtG PROPERTY OWNER INFoR,stalrloN.' CHEcXjF OWNER <br /> 1CuRRENn>•oHFKEwmEEHD <br /> PROPEWY(M"MNAME � <br /> t L{ <br /> 1. �. . __. rt• - I -- . 41 <br /> x+ 4R _ac Pr1OlE Ntmism <br /> BUS04EM NAME r �: 1E+MAa AaoaEas X40(� <br /> Owner Horne Address �V+ <br /> X130 Ory t lir C e.4) STATE <br /> Owner Mailing Addre s <br /> Malting Addre"City t l ( Stat' Zip I <br /> COePORATION INtNVIDUAL u PArtTt,ElraleP FED AOVOCY❑ Or1ER❑ <br /> SITE MiinaATION ENVIRONMENTAL ASaEsaMENT.�VOLUNTARY CLEANUP_ --WATER QUALITY._.HW P 10SLINE INVESTIGATION .. ,.�LOP <br /> F&CEM10a IN" AcomwrID PRIt1ROIt AssumeoEltta[.4tu LEADAoEmcr:CHO- _RWQC8_OTSCEPA <br /> —�_ <br /> jo <br /> FACILITY FILE COMPLETE r/r_EFOLLowrw BUSINESS I FACILITY/SITE INFORmARow <br /> Is this a NEW Business LOCATION not previously regulated by the ENvIRONMENTAL HEALTH DEPARTMENT? Yrs D NOX <br /> Is this a"E)a nNG Business LocAmN but a NEW TYPE of regulated 8u3in63s? Yes ❑ No <br /> BusaEsafFAcArrrrSrrE NAtt - - <br /> SrTE � surm f SUNK E/a PHONE <br /> � <br /> crn` STATE zw <br /> 80MD aF 31Rti3""wq,s Mabe, 3 LocATto[+CaoE I KEN, _ K.,2 L <br /> Ming Addrma NDOFFERENT/rOm FPG&dyAddre a Attention:orCare Of(opbomo <br /> Maitklg Address City <br /> STATE ZIP <br /> SIG CODE APN s COMMENT: <br /> TNIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BuaeNEle NAME 1 t - - A :orCare <br /> i M <br /> Mailing Addrasa PHONE <br /> Crff <br /> �'haclt io r� <,A mold <br /> AccowTADo ss for fees and charges OWNER FACIUTY/$USINESS THIRD PARTY BILLING <br /> 011 1 tv.N-e 1 V ANO"l r1H.%I!N l: I.the widenigned 1pplkani.certiF that I All,the!li ner.lJr,a rK+.r..,r I olh,wi:.-'d Tgent of IhL%Rusinns,and I orktkm letige Ihat all N RIM f rts. <br /> hi +, ,•\,!1+•.--eVl�I(Ne..r--\aid.ur!tri f l Nw,ri,••.,dated with this nperslimi%A be WW tome at the A+Idrem%.denhrwd abuse as the 1,.+i\T gnt,wr,.s h,r this sit,, I also cern[,That <br /> all 1nf,,rm.4wn pt.o drd+•n rhn appiwarr.,n,s true And c+inert And that all.,+,dared xlisiti. will he perk.rmrd in acc..rdartet w ith all■pptieahle 11,.104Qt-11('01',l) Ordinance(udn and:..r <br /> �trrrlArds and ti i 1 rr ati0.ur rr.K ksl I—amt I(eruosii+Ars. 1,the undenigned++w ner.uyrralwr.or went of the pn+pern kr rttnl al the allose hicif.h.site addrt.•m.1 IIrrcA�auElweve[he rckasr rd <br /> a— .nd all m.dn r.W rm in•nmrnlrl asan..nmt.nk.rman..n 1n r1\.{(11[11'IN f 4)1'%11 1 N%IR(I%AIF'%f A 1 Hl.(I.Til""'k"c17T -sw+ri As it it A•ailrhle And at the ssrwe rule 11 n <br /> pn,..ded W me.u..+)rep—T.ti,e- / <br /> APPLICANT NAME(PLLOM PRINT) Sarale Farms Inc By: Sandra SaralesmATUAE ��.<<TA-r.— .�� r _ _ ' <br /> LE TAx ID# <br /> TITLE Sarale,Controller 94-2265517 <br /> o.r r' <br /> SITE M;igATIOn I AUNT PAW DATE OF PAYIMEIR PAYMENT TYPE RECEIPT i CHECK i RrmrYEO BY WOIat PtAM PE <br /> FEE:[ <br />